AJMHS Issue 1 Vol 13 Jan-Jun 2013.cdr

African Journal of Medical and Health Sciences • Volume 12 • Issue 2 • Jan-Ju- 2014 • Pages 55-122

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ISSN 2384-5589

Issue 1 / Volume 13 / Jan-Jun 2014

African Journal of Medical and Health Sciences Official Publication of the Federal Teaching Hospital Abakaliki (FETHA), Nigeria www.ajmhs.org

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ORIGINAL ARTICLE

Pattern and outcome of admissions at the children emergency room at the Federal Teaching Hospital Abakaliki Onyinye U. Anyanwu1, Obumneme B. Ezeanosike1,2, Chinonyelu T. Ezeonu1,2 1

Department of Pediatrics, Federal Teaching Hospital, Abakaliki, 2Department of Pediatrics, College of Medicine, Ebonyi State University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria Address for correspondence: Dr. Anyanwu U. Onyinye, Department of Pediatrics, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria. E-mail: [email protected]

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ABSTRACT

Website: http://www.ajmhs.org/ DOI: 10.4103/2384-5589.139435 Quick Response Code:

Context: The children emergency room (CHER) in Federal Teaching Hospital Abakaliki (FETHA) is one of the units o pediatrics department specialized in meeting the unique needs of children during medical emergencies. A description of the pattern and outcome of its admissions and factors that may contribute to their outcome will help proffer solutions in health care planning with regards emergency care in Abakaliki. Aims: To determine the pattern and outcome of CHER admissions at Federal Teaching Hospital Abakaliki (FETHA). Materials and Methods: A retrospective study of CHER admissions from 1st of January to 31st of December 2012. The Nurses book of statistics and case notes of patients in the CHER of FETHA Ebonyi state, a multi-specialty, children’s referral, tertiary health hospital in Ebonyi State were used. Statistical analysis used: Descriptive analysis using SPSS version 20 (IBM statistics). Results: Over the period, 1022 patients were seen with a mean age of 1.9 + 2.6 years. Males were 58.8%, 41.2% were females. The most common diagnosis was diarrheal disease (36.1%) followed by malaria (16.2%) and pneumonias (11.7%). A mortality of 10% was recorded while 66.6% were discharged home, 3.8% discharged against medical advice while 19.6% were transferred to other units in the ward. Majority of deaths were in infancy (57.8%), more in males (69.6%), and from diarrheal disease (43.1%). Conclusions: There is a high mortality ratio of patients at CHER in our setting, attributable mainly to preventable causes like diarrhea. This raises concerns that parental education on health promoting and preventive measures may be low. Key words: CHER admissions, morbidity, mortality, outcome, pattern

INTRODUCTION The fundamental aim of the World Health Assembly by the Millennium development goals is to improve the quality of life of individuals and their survival through improved health care amongst others.[1] Emergency care especially for children is one of such services, which would improve their chances of survival.[1] Children Emergency Room (CHER) is a key area of service in every tertiary health institution

where pediatric emergencies are promptly handled on a day-to-day basis. It is a voluminous service area with a high patient turnover.[1] Performance evaluation of CHER of a hospital whether retrospectively or prospectively should be periodically carried out as information obtained from such studies could give an insight into the existing services with aims of improving them. Weekly mortality meetings are held in pediatric department FETHA where some mortality in the

Cite this article as: Anyanwu OU, Ezeanosike OB, Ezeonu CT. Pattern and outcome of admissions at the children emergency room at the Federal Teaching Hospital Abakaliki. Afr J Med Health Sci 2014;13:6-10.

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African Journal of Medical and Health Sciences / Jan-Jun 2014 / Vol 13 | Issue 1

Anyanwu, et al.: Pattern and outcome of cher admissions in FETHA

department as a whole are reviewed. No comprehensive review of the outcome of admissions in the Children Emergency room of FETHA has been carried out. Although reports of the pattern of childhood illnesses and deaths exist,[2-4] few have highlighted the outcome of children emergencies in Nigeria. Therefore, it becomes necessary to study the pattern and outcome of admissions at CHER FETHA. Nigerian studies have shown a predominance of infectious diseases as the major causes of morbidities in children. Ibeziako and Ibekwe[5] reported severe malaria with anemic heart failure followed by acute respiratory tract infections and diarrheal diseases as the most common causes of CHER admissions in Enugu South East Nigeria, which was similar to other reports by Iloh et al.[6] and Okechukwu[7] in Owerri and Abuja capital territory of Nigeria respectively. A similar pattern has also been shown with causes of mortalities with communicable diseases being the major causes of death from the emergency departments of children in Enugu,[5] Jos,[8] Lagos,[9] and Ilorin.[10] The Children Emergency Room (CHER) of Federal Teaching Hospital (FETHA) is a part of the ppediatrics department of FETHA, which aims at providing care for children who require prompt life-saving measures. They are discharged home or transferred to the pediatric ward as soon as possible usually within 24 to 48 hours. The staff of CHER Triage all patients according to the severity of their condition (Emergency Triage Assessment and Treatment; ETAT)[11] ensuring that the more critically-ill child is attended to first. This manuscript describes the outcome of admissions in CHER of FETHA where no such study has been done. It is hoped that this would provide a grounds for future studies and that it can be compared to other reports on similar topic from other centers.

It was a retrospective study of admissions at CHER of the Federal Teaching Hospital Abakaliki. The nurses’ records book as well as the case notes of patients admitted into CHER FETHA from 1st January to 31st December 2012 was reviewed. Obtained were data on age, sex, diagnosis, outcome, and duration of hospitalization. Outcome was classified as discharged home, transferred out to other unit, discharged against medical advice, and death. Analysis was done with SPSS version 20; results presented as proportions and means. Cross-tabulations of variables were done with the chi-square or fishers exact test where appropriate, and comparisons of means done with the students t-test. A value of P < 0.05 was taken as significant.

RESULTS A total of 1022 patients aged from birth to 18 years were seen with a mean age of 1.9 + 2.6 years during the period. Males were 601 (58.8%) while females were 421 (41.2%) giving a Male: Female ratio of 1.4:1. A representation of monthly admissions in Figure 1 shows that most of the admissions were in January, followed by November, September, and December, which correspond to the peaks of the harm at tan and the rainy seasons. Morbidity

Admissions were due to diarrhea (36.1%), malaria (16.2%), pneumonia (11.7%), anemic heart failure (9.5%), septicemia (8.0%), meningitis (6.0%), and others. Neonates were admitted on account of septicemia, omphalitis, and prematurity. Patients with sickle cell anemia were seen in various forms of crisis. Chronic cases like malignancies and chronic liver disease were also seen. Table 1 shows the various diagnoses for admission. Comparing the various morbidities with month of admission, malaria had a peak admission in November,

MATERIALS AND METHODS Children Emergency Room (CHER), FETHA, is an outcome of a merger of the former Federal Medical Center Abakaliki and Ebonyi State University Teaching Hospital Abakaliki. It is a complex consisting of a general ward, an isolation area, and the diarrhea treatment room. It also offers services such as blood transfusions and laboratory services with the help of other ancillary health workers. The staff work in shifts of about 6-8 hours every day, and CHER FETHA is open every hour of the day even on holidays. It receives its patients from the Children Out-patient Department of the hospital, some patients directly from home as well as referrals from other health institution within the state.

Figure 1: Showing average monthly admissions in CHER FETHA


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January, and September but was significantly seen throughout the year. Diarrhea peaked at January, which corresponds to the harm at tan period. Pneumonia was mainly in September at the peak of the rainy season after the August break. Anemic heart failure followed the same pattern as malaria peaking at January, September, and November. Meningitis had a single peak at December while septicemia was found in January, march, and November (χ 2 = 462.698; P = 0.000). There was no significant difference in the pattern of morbidity between males and females. Outcome

Table 2 shows that 681 (66.6%) patients were discharged home while 200 (19.6%) patients were transferred to other units. One hundred and two (10.0%) patients consisting of 71 (69.6%) males and 31 (30.4%) females died. A comparison of outcome by gender showed no statistically significant relationship. While 11.8% of males died, 7.4% of females died (χ2 = 7.021; P = 0.071). Thirty nine (3.8%) were discharged against medical advice with equal proportions of males and females. Mortality

Diarrhea was the most common cause of death accounting for 43.1% of deaths followed by septicemia (11.8 %), pneumonia (10.8%), malaria (9.8%), anemic heart failure (8.8%), meningitis (6.9%), and others as represented in Table 3. More deaths occurred in January and November (20.6% each) followed by deaths in December (15.7%) and then in September (10.8%). Majority of the mortality was in infancy (52.9%) followed by other under-fives (38.2%), both accounting for 91.1% of all deaths. There was 1 death in the 5-10 years age range while 3 (2.9%) deaths occurred amongst adolescents. Males accounted for majority of the mortalities (70%) while 30% of deaths occurred in females. Table 4 shows the various mortalities in the different age groups. In the Neonatal age group, the causes were bacterial sepsis, prematurity, and omphalitis, which were in newborns who were not born within the facility FETHA. Amongst the infants, diarrhea was the most common cause accounting for 51.9% of deaths in that age group followed by pneumonia (16.7%), sepsis (11.1%), anemic heart failure (7.4%), and malaria (5.6%). In the pre-school age patients, diarrhea was the most common cause of death (38.5%) followed by malaria (17.9%), anemic heart failure (12.8%), and meningitis (7.7%). The only death in the school age group was due to diarrhea while deaths in adolescence were due to chronic causes, chronic liver disease, and type 1 diabetes with late presentation. 8

The mean duration of hospitalization in CHER FETHA was found to be 45 + 20.3 hours with a mode (50.1%) falling between 24-48 hours. Anemic heart failure had a mean of 13.89 + 5.16 hours while the highest mean duration for hospitalization was protein energy malnutrition having a mean of 74.00 + 0.55 hours. The mean duration of hospitalization for diarrhea, septicemia, malaria, and pneumonia were 32.23 + 12.04 hours, 35.83 + 16.98 hours, 40.0 + 15.52 hours, and 44.00 + 16.9 hours, respectively. Deaths occurred most frequently within 24 hours, and this was statistically significant (χ2 = 190.366; P = 0.000). Table 1: Major diagnosis for admission Diagnosis Diarrhea Malaria Pneumonia Anemic heart failure Septicemia Meningitis Sickle cell anemia in crisis Malignancy Pyelonephritis Nephrotic syndrome Trauma Omphalities Protein energy malnutrition Enteric fever Type 1 diabetes Chronic liver disease Prematurity Others Total

Freq (%) 369 (36.1) 166 (16.2) 120 (11.7) 97 (9.5) 82 (8.0) 61 (6.0) 18 (1.8) 16 (1.6) 13 (1.3) 9 (0.9) 9 (0.9) 8 (0.8) 8 (0.8) 7 (0.7) 7 (0.7) 6 (0.6) 5 (0.5) 21 (2.1) 1022 (100.0)

Table 2: Outcome of cher admissions Outcome Discharged Died Dama Transferred Total

Freq (%) 681 (66.6) 102 (10.0) 39 (3.8) 200 (19.6) 1022 (100.0)

Male (%) 400 (66.6) 71 (11.8) 20 (3.3) 110 (18.3) 601 (100.0)

Female (%) 280 (66.7) 31 (7.4) 19 (4.5) 90 (21.4) 421 (100.0)

Table 3: Causes of mortality in CHER Diagnosis

Freq (percentage) Freq (percentage) of mortality of total sad missions Diarrhea 44 (43.1) 369 (36.1) Septicemia 12 (11.8) 82 (8.0) Pneumonia 11 (10.8) 120 (11.7) Malaria 10 (9.8) 166 (16.2) Anemic heart failure 9 (8.8) 97 (9.5) Meningitis 7 (6.9) 61 (6.0) Protein energy malnutrition 2 (2.0) 8 (0.8) Chronic liver disease 2 (2.0) 6 (0.6) Sickle cell anemia in crisis 1 (1.0) 18 (1.8) Prematurity 1 (1.0) 5 (0.5) Pyelonephritis 1 (1.0) 13 (1.3) Type 1 diabetes 1 (1.0) 7 (0.7) Omphalitis 1 (1.0) 8 (0.8)



Table 4: Showing the various causes of mortality in different age groups Diagnosis

0-28 1-12 days (%) months (%) 28 (51.9) 3 (60.0) 6 (11.1) 9 (16.7) 3 (5.6) 4 (7.4)

Diarrhea Septicemia Pneumonia Malaria Anemic heart failure Meningitis Protein energy malnutrition Chronic liver disease Sickle cell anemia in crisis Prematurity 1 (20.0) Pyelonephritis Type 1 diabetes Omphalitis 1 (20.0) Total 5 (100.0)

4 (7.4)

>12-10 years (%) years (%) (%) 15 (38.5) 1 (100.0) 3 (7.7) 2 (5.1) 7 (17.9) 5 (12.8) 3 (7.7) 2 (5.1)

requires 600 mls of water for its constitution. Therefore, the importance of increased campaign to improve the practice of ORS constitution and provision of measuring cups for its preparation is hereby stated. Other studies[5,7-10] showed that majority of deaths and morbidities were attributable to malaria, which was not the case with current finding. This may be because the diagnosis of malaria was separated from anemic heart failure where the anemia may be due to malaria, especially since the two morbidities had similar pattern of occurrence in the year.

2 (66.7) 1 (2.6) 1 (2.6) 1 (33.3) 52 (100.0)

39 (38.2) 1 (100.0)

3 (100)

DISCUSSION This study has shown the common causes of morbidity and mortality amongst children receiving CHER admissions in FETHA. Infections of various types is the leading cause of morbidity and mortality, which is similar to previous reports on the leading cause of childhood illnesses and mortalities.[2-4] WHO[12] recognize severe anemia, diarrheal diseases, and acute lower respiratory infections as the leading cause of childhood morbidities and mortalities, especially in the under-5 age group, and similar finding was made in current study. These infections, however, are preventable and/or are curable with minimal cost if they are recognized early or if presentations to hospital are made early. The persistence of similar pattern of morbidities in this study to previous documentations maybe due to persistence of those factors, which increased risk for infections in childhood. Deaths from diarrhea in this study ere were found to be majorly due to poorly constituted ORS with resultant hypernatremic dehydration. It is worthy of note here that despite UNICEF’s efforts to curb deaths from diarrhea by providing low osmolar ORS, that children still die from diarrhea due to poor constitution of ORS suggesting limited information or poor understanding of the populace on preparation of ORS. More so, the absence of commercially graduated 1 eliter cups to measure the water volume for constituting commercial ORS makes mothers often time approximate the quantities to be mixed. There may also be a mix-up of the quantity of water to be used for reconstitution because while most commercial ORS requires 1 eliter of water, the home-made salt sugar solution recipe

The outcome with regard to discharge home and transfers’ to the ward is encouraging and justifies the presence of the unit for prompt management of acute life-threatening pediatric illnesses. However, adequate resources in the form of increased man-power and equipment should be put in place to improve the outcome of admissions, especially during the identified periods where the mortalities for the various morbidities have their peaks. The 10% mortality recorded here is remarkably higher than that by other Nigerian authors[5,7-10] probably because of the higher prevalence of diarrhea in this study when compared to other studies. The outcome with respect to discharge against medical advice is remarkable higher than 0.1% reported previously amongst emergency room admissions in Enugu[5] and also lower than 1.5% reported amongst pediatric patients in Abakaliki 4 years ago.[13] It was, however, similar to that reported in Asaba[4] and Abuja.[14] The previous study on DAMA, even though it was carried out in one of the institutions which made up the current FETHA, was done on all pediatric patients and not just on admissions within the emergency room. The current finding of 3.5% for DAMA may be attributed to the diagnosis since most of those who were discharged against medical advice had chronic illnesses and may have preferred to seek other sources of help. Also, DAMA was found amongst those who required blood transfusions but were of the Jehovah’s Witness denomination. Duration of hospitalization was significantly associated with outcome (χ2 = 190.366; P = 0.000) as most of the deaths occurred within 24 hours so that the longer staying patients were more likely to be discharged. This also suggests that late presentation might be a contributing factor to mortality since more deaths were recorded in the first 24 hours. Evidence for this had already beenen given by Iloeje[15] who showed that late presentations to hospital may be responsible for high mortalities in Nigerian Children. Continued health education through the media and during community visitations will help change the healthseeking behaviors of care-givers in order to curb this.


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CONCLUSION

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Pattern of morbidity has remained similar; high mortality rates in children vehave also persisted, especially in the very young children. The existence of CHER has gone its way in maintaining a high rate of discharges and transfersin. However, efforts need to be intensified to reduce the proportions of deaths and to curb DAMA in this center. Continued health education, promotion of child survival strategies at the community level, combined with an improvement in the socio-economic circumstance of the populace may further improve survival of children in our area.

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Source of Support: Nil, Conflict of Interest: None declared.
